Active feet are happy feet. William Salcedo, D.P.M ......With this consent, I understand that...
Transcript of Active feet are happy feet. William Salcedo, D.P.M ......With this consent, I understand that...
Active feet are happy feet.
New Patient Information Form(Please Print)
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
William Salcedo, D.P.M.Diplomat American Board of Podiatric Surgery
Board Certified in Foot Surgery
Social Security #:
Patient Name:Last First MI
Date: / /
Date of Birth: / / Age: Sex: M F
Primary Address: City/State: Zip:
Secondary Address: City/State: Zip:
Primary Phone #: ( ) - Secondary Phone #: ( ) -
E-mail: Primary Language:
Se Habla Español
Race: White |
|
American Indian or Alaska Native | Asian | Black or African American | Native Hawaiian or Pacific Islander
Ethnicity: Hispanic or Latino |Non-Hispanic or Non-Latino
Do you have a legal guardian or healthcare power of attorney? Yes | No
If yes, Name: Relationship:
Cell Phone #:( ) -
Emergency Contact: Relationship:
Cell Phone #:( ) -
Primary Care Doctor:
Who referred you to us? Physician | Friend | Family | AT&T YP | Insurance | Online YP | Website
Pharmacy: ( ) -Address:
Is there a family member or other person you would like for us to share your medical information?
Yes Name (s) No
Are you a student? Yes | No If yes, full time or part time
Are you employed? Yes | No If yes, full time or part time
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1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Current Problem
What specific problem brings you to our office today?
Where is the pain/problem located? (please mark with pen or pencil on the pictures below)
Top of Foot Bottom of Foot
Left Foot Right Foot
Bottom of Foot Top of Foot
How long ago did this problem first start? Days | Weeks | Months | Years
Did your pain or problem: Begin all of the sudden | Develop over time
How would you describe your pain? No Pain | Sharp | Dull | Aching | Burning | Radiating | Itching | Stabbing
Other
How would you rate your pain on a scale from 0 to 10? 0 |(no pain) 1 |2 |3 |4 |5 |6 |7 |8 |9 |10 (worst pain)
What makes your pain or problem feel worse? Walking | Standing | Daily Activities
Since the time your pain or problem began, has it: Stayed the same | Become worse | Improved
| Resting | Dress Shoes
|High heels |Flat shoes |Any closed toe shoe |Running Other
What makes your pain or problem feel better?
What treatments have you had for this problem?
How was this problem affected your lifestyle or ability to work?
Was this problem caused by an injury? Yes (describe) No|If yes, was it a work-related injury?
Yes No|Have you ever been treated by a podiatrist? What for?
Yes No|
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Please list all medications you are currently taking (include prescriptions, over-the-counter meds and herbal supplements):If you brought a list to this appointment, please hand it in when all paperwork is complete and you will not be required tocomplete this section
Name: Dose:
Please list all prior foot surgeries:
Type of Surgery Dat:
Marital Status: Married | Partnered |
Social History
Single | Separated | Divorced | Widowed
Use of Alcohol: No Longer Use | History of Alcohol AbuseNever | | Current Use - Type
Occasional |Rare | Moderate | Daily
Use of Tobacco: Quit Never | How long ago? Smoke| Packs/Day for years
(All patients 13 years and older are legally required to answer.)
Does anyone in the family smoke? No
Never |
If Yes, who?
Use of Recreational Drugs: Quit How long ago? Type
Current Use Type | Rare | Occasional | Moderate |Daily
How much are you on your feet at work? 10% | 25% | 50% | 75% | 100%
Do others depend upon you for their care? Children Age(s) | Pets What kind?
Elderly or disabled family member | Other
Exercise: RareNever | Occasional| Weekly| Several times a week| Daily|Types of exercise:
Do you have a family history of: Diabetes |
Family History
Cancer | Heart Disease | High Blood Pressure | Stroke
Coronary Artery Disease | Thyroid Disease | Rheumatoid Arthritis | Other
Allergies: None Known |
Your Medical History
Medications
Anesthesia
Yes |
Foods|
Tape Other| Latex | Shellfish | Iodine |
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Have you ever had any of the following? (Please only check the ones that apply)
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrectinformation can be dangerous to my health. I understand that it is my responsibility to inform the Doctor and office staff of anychanges in my medical status. I give my permission for Dr. William Salcedo to administer treatment as may be deemed necessary in the diagnosis and/or treatment of my foot/ankle condition.
Print name of patient, parent or guardian
Atrial Fibrillation
Anemia
Acid Reflux
Arthritis
Rheumatoid
Asthma
Back Trouble
Bladder Infections
Abnormal Bleeding
Blood Clots
Blood Transfusion
Bronchitis/Emphysema
CABG
Cancer
Diabetes
Chest Pain
Insulin Dependent
Non-Insulin Dependent
Fibromyalgia
Heart Attack
Gout
Heart Disease/Failure
Hepatitis
HIV +/Aids
High Blood Pressure
High Cholesterol
High Lipids
Kidney Disease
Dialysis
Liver Disease
Low Blood Pressure
Low Back Pain
Mitral Valve Prolapse
Migraine Headaches
Neuropathy
Other:
Open Sores
Pacemaker
Osteoporosis
Pneumonia
Polio
Rheumatic Fever
Shortness of Breath
Sickle Cell Disease
Skin Disorder
Sleep Apnea
Stomach Ulcers
Stroke
Thyroid Disease
TIA
Valve Disease
Tuberculosis
Other:
Signature of Doctor
If other than patient, relationship to patient Date
Signature
Date
Osteo
Patient Consent for Use and Disclosure of Protected Health Information
PATIENT NAME: _______________________________________________________________
I hereby give my consent for William Salcedo, DPM, PA to use and disclose
carry out treatment, payment, and health care operations (TPO). This information may be mailed, faxed or e-mailed
electronically through a HIPAA protected portal. In order to receive protected communication and access to my
electronic medical records, I must provide my e-mail address to this office. I may send and receive e-mails through a
HIPAA protected e-mail portal or through IQ health, our patient portal. William Salcedo, D.P.M., PA’s Notice of
Patient Privacy Practices provides a more complete description of such uses and disclosures and is available upon
request.
With this consent, I understand that William Salcedo, D.P.M., P.A. employees may call my home phone, cell phone,
leave a voice mail on either phone, send an e-mail, or communicate via a patient portal to confirm an appointment
1-2 days prior to that appointment. Employees may also communicate in the same methods in reference to any items
that assist the practice in carrying out TPO, handling insurance issues, and communication about my clinical care;
this would include lab results among other items.
Patient statements may be mailed to my home or other location and will be marked Personal and Confidential.
William Salcedo, DPM, PA will send a thank you note as well as a copy of the initial office visit note to the referring
physician.
By signing this form, I am consenting to William Salcedo, DPM, PA’s use and disclosure of my PHI to carry out TPO.
I know that I may request a copy of William Salcedo, DPM, PA’s Privacy Practices.
protected health information (PHI) to
Print name of patient, parent or guardian
If other than patient, relationship to patient
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Signature
Financial Policy
PATIENT NAME: _______________________________________________________________
Print name of patient, parent or guardian
If other than patient, relationship to patient
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Signature
I understand the following:
William Salcedo, DPM, PA is a participating provider for most insurance companies allowing me to receive financial discount available through my particular insurance company. My insurance benefits will be verified in order to accurately determine my financial responsibility; co-payments, deductibles, and co-insurance are always due at the time of service. The amount collected is an estimate of what will be due, and so I may receive an invoice for the balance after the claims are processed. This office submits all claims to my insurance company (s). I understand that payment is due upon receipt.
If I become a surgical patient, I will be responsible for paying co-payments, deductibles, and co-insurance at my pre-op consent appointment.
If my address changes, I will update it with William Salcedo, DPM, PA's office. I understand that payment is due within 15 days of invoice mailings. I have been notified that accounts may be sent to collections if balances are not paid within 45 days of the initial invoice mailings. If I am sent to collections because I am delinquent in paying my balance, I will be responsible for collection costs in addition to the outstanding balance; I understand that collection costs are approximately 30% of the original balance.
If I ever have a question about a claim, I will call Janice at 772-337-0014.
the greatest
Responsible Party Information
Name:
DOB:
Cell Phone:
SS#:
Employer:
Employer Phone #:
Address:
Spouse’s Name:
Spouse’s DOB:
Spouse’s Cell Phone:
Spouse’s SS#:
Spouse’s Employer:
Spouse’s Employer’s Phone#:
Assignment of Benefits
Print name of patient, parent or guardian
If other than patient, relationship to patient
1331 SE Port St. Lucie Blvd. Suite 101 Port St. Lucie, FL 34952 | PH: 772-337-0014 | FX: 772-398-0887 | SalcedoPodiatry.com
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Signature
Patient Name: _______________________________Date of Birth:_____________________
I authorize the release of any medical or other information necessary to process my
insurance claims. I also authorize payment of insurance medical benefits from the
government or private insurance companies to William Salcedo, DPM, PA for services
rendered. I am authorizing this signed form to be kept on file and for copies of this
form to be used in place of the original. This authorization is to apply to all claims filed
on my behalf that are sent to my current insurance companies or those that I may have
in the future.
Signature
ACKNOWLEDGMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of William Salcedo DPM, PA’s Notice of Privacy
Practices and that I have read (or had the opportunity to read if I so chose) and understood the
Notice.
Patient Name (please print) Date
Parent or Authorized Representative (if applicable)
Signature